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|
Attributes | |
ACN | 610842 |
Time | |
Date | 200403 |
Day | Tue |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 610842 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On mar/tue/04, I was assigned aircraft which needed pm check, spindle check, software download cds. Arriving XA05 same time as my other aircraft, I never done cds download, but was aware of 3 hour process. So my focus was to at least get download started, in case there's a problem. Consist of 8 disks per captain and first officer checking MPD25. I started download, while working other task. Checking loading every 10-15 mins inserting next disk, captain side, then started first officer's download. So I shut down loader, and restart process. While waiting and watching, I started checking and signing paperwork, during my logbook entry for pm check. So the first officer's load seems to be going ok. Then I started to think at this time I should at least go take a look at my other aircraft in case of structural damage or other problems to address. So I would work 10-15 mins on other aircraft came back, check load process and insert next disk. This continued to final disk, knowing I had sign off pm check, spindle check, logbook entries prior. I disconnect loader verify download, shut down aircraft, pull log page, totally forgetting to get the hgs re-certified. Even in the shop checking paperwork and date stamping, not realizing I had sign off hgs re-certification line prior, I miss the task again. Then I went back to complete my other aircraft. On the next night, mar/wed/04, when I got to work someone asked me about cds download process. I remember then I had forgotten to get hgs recertification. I called as soon as possible and the call maintenance control team leader to make sure the aircraft was recertified hgs soon as possible. My first mistake was trying to save time by signing aircraft paperwork while finishing up first officer's download, and not paying close attention to each sign-off line.
Original NASA ASRS Text
Title: A B737-700 WAS DISPATCHED IN NON COMPLIANCE WITH THE HEADS UP GUIDANCE SYS NOT RECERTIFIED AND NOT DEFERRED OR PLACARDED.
Narrative: ON MAR/TUE/04, I WAS ASSIGNED ACFT WHICH NEEDED PM CHK, SPINDLE CHK, SOFTWARE DOWNLOAD CDS. ARRIVING XA05 SAME TIME AS MY OTHER ACFT, I NEVER DONE CDS DOWNLOAD, BUT WAS AWARE OF 3 HR PROCESS. SO MY FOCUS WAS TO AT LEAST GET DOWNLOAD STARTED, IN CASE THERE'S A PROB. CONSIST OF 8 DISKS PER CAPT AND FO CHKING MPD25. I STARTED DOWNLOAD, WHILE WORKING OTHER TASK. CHKING LOADING EVERY 10-15 MINS INSERTING NEXT DISK, CAPT SIDE, THEN STARTED FO'S DOWNLOAD. SO I SHUT DOWN LOADER, AND RESTART PROCESS. WHILE WAITING AND WATCHING, I STARTED CHKING AND SIGNING PAPERWORK, DURING MY LOGBOOK ENTRY FOR PM CHK. SO THE FO'S LOAD SEEMS TO BE GOING OK. THEN I STARTED TO THINK AT THIS TIME I SHOULD AT LEAST GO TAKE A LOOK AT MY OTHER ACFT IN CASE OF STRUCTURAL DAMAGE OR OTHER PROBS TO ADDRESS. SO I WOULD WORK 10-15 MINS ON OTHER ACFT CAME BACK, CHK LOAD PROCESS AND INSERT NEXT DISK. THIS CONTINUED TO FINAL DISK, KNOWING I HAD SIGN OFF PM CHK, SPINDLE CHK, LOGBOOK ENTRIES PRIOR. I DISCONNECT LOADER VERIFY DOWNLOAD, SHUT DOWN ACFT, PULL LOG PAGE, TOTALLY FORGETTING TO GET THE HGS RE-CERTIFIED. EVEN IN THE SHOP CHKING PAPERWORK AND DATE STAMPING, NOT REALIZING I HAD SIGN OFF HGS RE-CERTIFICATION LINE PRIOR, I MISS THE TASK AGAIN. THEN I WENT BACK TO COMPLETE MY OTHER ACFT. ON THE NEXT NIGHT, MAR/WED/04, WHEN I GOT TO WORK SOMEONE ASKED ME ABOUT CDS DOWNLOAD PROCESS. I REMEMBER THEN I HAD FORGOTTEN TO GET HGS RECERTIFICATION. I CALLED ASAP AND THE CALL MAINT CTL TEAM LEADER TO MAKE SURE THE ACFT WAS RECERTIFIED HGS SOON AS POSSIBLE. MY FIRST MISTAKE WAS TRYING TO SAVE TIME BY SIGNING ACFT PAPERWORK WHILE FINISHING UP FO'S DOWNLOAD, AND NOT PAYING CLOSE ATTN TO EACH SIGN-OFF LINE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.